The majority of patients with duodenal ulcer (DU) are infected with Helicobacter pylori (H. pylori). However, in multicenter trials, H. pylori was absent in almost 30 percent of patients with an endoscopically documented duodenal ulcer [1]. Studies that have investigated these patients found that they have generally had a shorter duration of symptoms and that many had regularly used nonsteroidal antiinflammatory drugs (NSAIDs) [2-4]. Such patients have a significantly worse outcome, especially if treated empirically for H. pylori infection. Thus, H. pylori status should be determined in all ulcer patients before initiating treatment [4]. High acid output may be a cause of recurrent DU in patients in whom H. pylori has been eradicated [5]. A variety of other causes are responsible for the remaining cases. (See "Unusual causes of peptic ulcer disease".)

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